Diagnosis: severe bacterial infection

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld.

This male patient has a history of hyperbilirubinemia requiring phototherapy. He presented to the emergency room (ER) with complaints of a fever, nasal congestion, decreased intake, and decreased output. Temperature was 102.2 F. Labs revealed leukopenia with neutropenia. The physical examination revealed mild pharyngeal erythema, no petechiae, and no exudates. A chest x-ray (CXR) revealed findings that were suspicious for bronchiolitis or atypical viral pneumonia. The patient was given 120 milligrams (mg) of rectal Tylenol and intramuscular (IM) Ceftriaxone. The infant was bagged. There was a suspicion for a severe bacterial infection (SBI.) He was admitted on for further care. Vital signs were monitored as per protocol. 3-4 ounces (oz) of formula was given every 3-4 hours (Q3-4H.) Ceftriaxone was given once a day (QD.) Intake and output was monitored. Tylenol was given as needed (PRN) for fever. Blood cultures were negative. By the time of discharge the infant remained stable for more than 24 hours and vitals were stable. He was discharged on with instructions to follow up with the primary care physician (PCP) within 2-3 days of discharge.

A chest x-ray revealed findings that were "suspicious for bronchiolitis or atypical viral pneumonia". About 1 hour after arrival complete blood count (CBC) showed borderline leucopenia of 4,900 with an absolute neutrophil count (ANC) of 1000, and low platelets 58,000. About 2 hours later CBC showed leucopenia 3,600 with an ANC of 1000 again, but platelets normal at 276,000. C-reactive protein (CRP) was normal. All other lab parameters were within normal limits. The stated justification for admission is suspicion for a severe bacterial infection (SBI.) However, he did not meet criteria for SBI because he was not in the high-risk age range nor was toxic appearing. (Sherman and Sood)
He did not have thrombocytopenia. The first low count was likely a lab artifact. He had borderline leukopenia and borderline neutropenia, which can be attributed to his viral infection, and was not an indication for antibiotic therapy. His band count was 6%, which can be seen in a viral infection.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.